The effect of training problem-solving skills for pregnant women experiencing intimate partner violence: a randomized control trial

Introduction Intimate partner violence (IPV) in pregnancy is considered as an additional threat to the maternal/fetal health. The present study was aimed to investigate the effectiveness of training problem-solving skills on IPV against pregnant women. Methods The present randomized clinical trial was conducted on 125 and 132 women visiting the health centers of Tehran as the intervention and the control groups, respectively; samples were selected using random stratified cluster sampling. The intervention group underwent four problem-solving training sessions. Three months later, both groups completed the revised Conflict Tactics Scale questionnaire. Data were analyzed using SPSS v.16. Results The mean (SD) ages of the participants were 27.51 (4.26) and 27.02 (4.26) years, respectively, in the control and the intervention groups. The rates of the physical and psychological violence were significantly reduced after the intervention in the intervention group. Risk differences of the physical, psychological and sexual violence before and after the intervention were 3% (95% CI: -8.23 to14.13, P = 0.6), 1.5% (95% CI: -4.93 to 8.03, P = 0.6) and 4.8% (95% CI: -7.11 to 16.52, P = 0.4) in the control group and 8.8% (95% CI: -3.47 to 20.71, P = 0.1), 25.4% (95% CI: 15.77 to 34.66, P < 0.001) and 4.9% (95% CI: -7.38 to16.97, P = 0.4) in the intervention group, respectively. Conclusion It seems that training this skill as a part of the routine prenatal care could be effective in reducing intimate partner violence.


Introduction
Intimate partner violence (IPV) is an act of physical, sexual and emotional-psychological abuse by the partner and is considered a health problem throughout the world [1]. According to the World Health Organization (WHO), physical violence may take place in the form of slapping, throwing objects, pushing, punching, kicking or using any weapons to harm the other person; sexual violence involves engaging in any sexual act through force or out of fear and any act that humiliates the woman; emotional violence involves the acts of disrespect, insult, disdain, isolation from the family and friends, controlling decision-making etc [2]. Although physical violence is more easily recognized due to its battering signs, psychological and emotional violence are substantially more harmful [3]. Recent studies by the WHO and the demographic health surveys (DHS) conducted in different countries indicated a varying prevalence of domestic violence against women by their intimate partners, ranging from 15% to 75% in a lifetime [4]. A nationwide survey carried out in 28 province centers of Iran showed that 30% of married women have at least experienced one type of intimate partner violence in their lifetime [5]. Due to its violation of human rights and the great effects on the community's health and development, intimate partner violence has become a major global concern [6]. In some studies, pregnant women are recognized as one of the most vulnerable groups of victims of this violence [7] and the most common type of violence is, in fact, intimate partner violence against pregnant women [8]. In a systematic global review, the prevalence of intimate partner violence against pregnant women was reported as 1% to 20% [6], reaching 15% to 71% in low to middle-income countries [9] and 4% to 48% in Asian countries [6].
In Iran, the mean prevalence of IPV against pregnant women was reported as more than 60% [10]. In a study conducted in Tehran province, 60.6% of pregnant women had experienced different types of IPV, with 60.5% reporting psychological, 23.5% sexual and 14.6% physical violence [5]. For many reasons, the reported statistics are lower than the actual figures [11]. The type of committed intimate partner violence is different for women who are experiencing it for the first time during their pregnancy. A study by Martin et al (2004) showed a relationship between pregnancy and increased psychological and sexual violence, even in women with no experience of violence before pregnancy. A number of studies have shown that emotional-psychological violence is highly likely to continue into pregnancy in women with the experience of IPV before their pregnancy [12].
The complications caused by IPV during pregnancy are associated with the type of experienced violence. There is a significant relationship between verbal abuse and low birth weight. Sexual violence during pregnancy can also lead to placental abruption, miscarriage and preterm labor [13], while physical violence during pregnancy is associated with direct effects on the fetus, including fetal bone fractures or fetal death [5]. Irrespective of the changes in the type of the committed IPV against pregnant women, pregnancy is, in fact, the best time for performing interventions on abused women [14]. During pregnancy, intimate partner violence is more prevalent than other common complications such as preeclampsia and gestational diabetes [15], which are among the main causes of maternal mortality [12] and for which women are routinely examined [16]. In fact, pregnancy is a high-risk period for abused women, when the health of both the mother and the fetus is at risk [17]; and when the health is even further threatened with the adoption of inappropriate coping strategies against intimate partner violence [18]. Abused pregnant women use various coping strategies to deal with intimate partner violence. In a study conducted by Zakar et al (2012), most abused pregnant women in Pakistan used coping strategies such as avoiding their spouse, participating in religious ceremonies and events, joining local support networks, asking for help from the family and friends or reticence, which, although have been helpful in reducing the physical violence, had no effect on psychological violence [19].
Problem-oriented coping is a coping strategy adopted in stressful conditions that focuses on the existing problem, plans for solving it and pursues help in others [20]. The problem-oriented coping strategy is closely connected to problem-solving skills. Problemsolving skills are therefore crucial life skills that everybody should possess [21]. Problem-solving skills are a great help to doctors, who often use it in therapy sessions. The assumption is that successful problem solving reduces people's incompatibility and leads to positive compatibility in a life filled with routine problems [22]. In one study, however, teaching to forgive one's spouse was reported to be a more effective strategy than life skills training (including problem-solving skills) in improving symptoms of depression and anxiety in abused women [23].
Health centers are frequented more often by women of reproductive age and pregnant women who seek medical care [24]. Various studies have shown that, for many different reasons, pregnancy [15] is the best time for performing interventions in health centers in order to reduce and prevent the risk of IPV against them; the first reason is that 95% of pregnant women visit the health centers during pregnancy to receive routine pregnancy care [25]; second, due to the changes taking place in the woman's role (i.e, the adoption of a maternal role) and her wishes to protect the fetus and herself, pregnancy is a suitable period for training behavior changes; and third, regular visits to the health center during pregnancy could lead to an empathic and trusting relationship between the mother and the midwife [15]. It has been witnessed during the recent decades that countries have prioritized identifying

Methods
The present quasi-experimental study was conducted in Tehran  in the control and the intervention groups referred to receive support services at the end of the study. The researchers asked the question of "Whether you referred to receive support services" at the beginning of each session, to control the effect of receiving supportive services. For calculating the prevalence of each type of violence, first, the score of each type of violence was divided into two states of zero and more than one; zero meant not having experienced violence and more than one meant, having experienced violence during the past year. Accordingly, the rate of violence was measured and compared before and after the intervention in both groups via risk difference and relative risk. All the analyses were performed using SPSS V.14.  Table 2. According to Table 3, there were no significant differences between the types of experienced IPV before the intervention, in the two groups. But, results of relative risk showed that the rate of physical and Psychological violence was significantly

Discussion
Researchers have not reached a consensus regarding the prevalence of IPV during pregnancy [24]. Pregnancy can lead to changes in the overall prevalence of intimate partner violence [29] and is thus the best time for assessing the prevalence of IPV.
Various studies have shown that women with a history of committed violence against them have no desire to disclose their experiences; however, due to their frequent visits to pregnancy care centers to receive routine pregnancy care (almost 90%) and their ongoing relationships with the health service providers [16], particularly with the midwives, pregnancy provides a window of opportunity for assessing the prevalence of IPV against women [14]. In   [16], which is inconsistent with the findings of the present study, perhaps due to the cited study's smaller sample size and the different type of questionnaire that was used to examine the participants. In the present study, the prevalence of psychological , which is inconsistent with the results of the present study; nevertheless, no significant differences were observed 6 and 12 months after the intervention, which is inconsistent with the results of the present study. According to the researcher, the disparity of the results may be due to the type of the used questionnaire in the cited study (the ASS), its follow-up period (6 and 12 months after the intervention), its intervention design (the empowerment of abused women in three sessions) and the performed intervention in the control group (which was provided through brochures containing information on sources of support during violence). The problem-solving ability is the same as the previous experience of dealing with problems, determining the barriers to solving the problem, and motivating for behavior change.
The behavior of solving the problem is associated with personal attributes and thus people with problem-solving skills are more successful in dealing with problematic situations.

Conclusion
It seems that teaching problem-solving skills can reduce these psychological types of intimate partner violence against pregnant women and their complications, since through this skill, pregnant women can learn to choose the best way out of all possible ways for dealing with their husband's physical and psychological violence (e.g, behavior change at the time of violence). Other skills such as assertiveness (being able to say no to inappropriate sexual demands by men) may be helpful in reducing the sexual type of violence against women. In general, irrespective of the type of the  Table 1: The content of the problem-solving training sessions Table 2: Demographic characteristics of the control and the intervention groups separately Table 3: Frequency of the types of intimate partner violence before and after the intervention in the intervention and the control groups  General briefing on the problems occurring in a marriage, coping with problems (problem-oriented and emotionoriented coping strategies) and introduction to the components of problem-solving skills.

Tables and figure
2 The first and second stages of problem-solving skills training (accepting and carefully defining the problem). 3 The third and fourth stages of problem-solving skills training (brainstorming and solution assessment).

4
The fifth and sixth stages of problem-solving skills training (implementing the best solution and a review of the chosen solutions).